Have you ever felt so overwhelmed by emotion that reality itself seems to bend? For individuals with damage to a specific part of the brain, this isn't just a fleeting feeling—it's a daily experience. This condition, known as memory-related confabulation, causes people to create false memories without any awareness that they are untrue (Fotopoulou, 2010). It’s a journey into a fractured mind, where wishing can literally feel like reality.
This exploration, inspired by Curtis Holt-Robinson’s dissertation, "How Wishing Becomes Reality," dives into the compassionate world of psychoanalytic therapy. We'll discover how this gentle, relational approach offers a path to healing for those with damage to the ventromedial prefrontal cortex (vmPFC). You will learn:
- How vmPFC damage affects emotional regulation and memory (Bechara et al., 2000; Hiser & Koenigs, 2018).
- Why confabulation is often an emotional, not just a cognitive, issue (Salas & Turnbull, 2010; Solms, 2000).
- How the safety of the therapeutic relationship can mend a fragmented sense of self (Tiberg, 2014; Ogden, 2004a).
- The transformative power of psychoanalytic techniques in promoting healing and growth (Bion, 1962; Ogden, 2004c).
The Brain’s Emotional Heart: Understanding the vmPFC
Deep within our frontal lobes lies the ventromedial prefrontal cortex, or vmPFC. Think of it as the brain's emotional regulator and self-storyteller. The vmPFC is crucial for several functions that make us who we are:
- Decision-Making: It helps us weigh long-term outcomes based on past emotional experiences (Bechara & Van Der Linden, 2005; Tranel et al., 2002).
- Autobiographical Memory: It’s most active when we recall deeply personal and significant moments (Bonnici & Maguire, 2018; Benoit et al., 2014).
- Emotional Regulation: It works to calm intense emotional responses, keeping us stable and predictable (Etkin et al., 2015; Hiser & Koenigs, 2018).
When the vmPFC is damaged, often through a traumatic brain injury or aneurysm, these abilities become impaired (DeLuca et al., 1996; Mackey & Petrides, 2014). The result is often a state of emotional dysregulation, where feelings can become overwhelming and erratic. This is where memory-related confabulation often begins (Turnbull & Salas, 2017; Solms, 2000).
When Memory Becomes a Story: What is Confabulation?
Confabulation is more than just poor memory; it's the creation of false or distorted memories without the intention to deceive (Fotopoulou, 2010). An individual might vividly describe events that never happened, believing them to be entirely true. Curtis's research highlights a profound insight: these confabulations aren't random. They are often wishful, painting a reality that is more pleasant or manageable than the person's current, often difficult, circumstances (Fotopoulou et al., 2004).
This "emotional-dysregulation hypothesis" suggests that confabulation is a protective, albeit unconscious, act (Salas & Turnbull, 2010). The mind, struggling to process distressing emotions linked to the injury or its consequences, reconstructs reality. It crafts a story to shield the self from emotional pain that feels too overwhelming to bear (Feinberg, 2010; Solms, 2013). In this way, confabulation becomes a creative, if flawed, attempt to maintain a sense of coherence and well-being.
The Limits of Logic, The Power of Connection
Traditional cognitive therapies for confabulation often focus on fact-checking. The therapist might challenge the patient's false memories with external evidence, pointing out inconsistencies (DeLuca, 1992; Metcalf et al., 2007). While this can sometimes reduce the frequency of confabulations (Francis et al., 2022), it can also come at a high cost.
Patients may feel constantly corrected, leading to feelings of inadequacy, frustration, and depression (DeLuca, 1992). They might learn to distrust their own minds entirely, answering every question with "I don't know" for fear of being wrong. This approach can leave the individual feeling emotionally isolated, their underlying distress unheard and unaddressed (Solms, 2012). It misses the heart of the matter: the emotional story the confabulation is trying to tell (Salas & Turnbull, 2010).
Psychoanalytic Therapy: A Space to Feel and Heal
Psychoanalytic therapy offers a different path—one rooted in empathy, connection, and emotional truth (Ogden, 2004c; Music, 2014). It creates a safe, non-judgmental space where the individual’s inner world can be explored with gentle curiosity rather than correction. This approach recognizes that healing comes not from erasing the "wrong" stories, but from understanding the feelings that created them (Solms & Friston, 2018).
Several core principles of psychoanalysis are uniquely suited to help individuals with vmPFC damage and confabulation.
1. Transference: The Relationship is the Therapy
In psychoanalysis, the relationship between the therapist and the patient is the primary vehicle for change. Transference is the process where a patient unconsciously projects feelings and relational patterns from their past onto the therapist (Freud, 1912; Smith & Solms, 2018).
For a patient with vmPFC damage, this can be very concrete. They might genuinely believe the therapist is a lover, a parent, or a friend (Solms, 2000; Tiberg, 2014). A skilled psychoanalytic therapist understands this not as a delusion to be corrected, but as a vital communication. These confabulations about the relationship reveal the patient's deepest needs, fears, and desires for connection. By accepting and exploring these feelings within a safe container, the therapist helps the patient begin to integrate them (Ogden, 2004a; Heimann, 1950).
2. Symbolization: Turning Raw Emotion into Meaning
Overwhelming, unprocessed emotions are like raw sensory data—what psychoanalyst Wilfred Bion called "beta-elements" (Bion, 1962). They are chaotic and unthinkable. The goal of therapy is to transform this raw experience into "alpha-elements"—symbols, images, and words that give the feelings meaning. This process is called symbolization (Segal, 1957; Green, 1975).
A compassionate therapist acts as a container for the patient's unbearable emotions (Ogden, 2004a; Loewald, 1960). Through their calm, attuned presence, they help metabolize the distress. For example, a patient might confabulate a story about a past catastrophe. Instead of challenging the facts, the therapist might gently wonder about the feeling of fear or helplessness in the story, helping the patient connect with the emotion without being overwhelmed by it (Alvarez, 2010). This shared experience makes the unbearable, bearable.
3. Working-Through: Building a Stronger Self
Healing is not a one-time event; it's a process of working-through (Freud, 1914; Weiss, 2014). As the patient feels safer in the therapeutic relationship, they can begin to experience and mourn the reality of their injury and its impact on their life. They develop a greater tolerance for distressing emotions (Bion, 1962; Ogden, 2017).
This was seen in the case of "Emma," a patient discussed in Curtis’s work (Tiberg, 2014). Initially, her confabulations were entirely pleasant. As her relationship with her therapist deepened, she began to express anger and sadness, first about past events, and eventually about her present limitations. While painful, this shift marked a profound step toward healing. She was no longer running from her reality but beginning to face it, supported by the unwavering presence of her therapist.
A Journey Back to Wholeness
Psychoanalytic therapy provides a powerful and humane path for individuals grappling with vmPFC damage and confabulation (Salas et al., 2019; Solms & Friston, 2018). It shifts the focus from correcting facts to honouring feelings. It understands that beneath the most confusing stories lies a human heart trying to find its way back to safety and connection (Ogden, 2004a).
This journey of healing nurtures the mind's ability to tolerate distress, symbolize experience, and build a more authentic, integrated sense of self. It is a testament to the idea that even in the face of profound neurological injury, the human spirit's capacity for growth and transformation is boundless when held in a space of true empathy and compassion (Music, 2014; Bion, 1979).
If you or a loved one is navigating the complexities of a brain injury, know that there is hope. Innovative and compassionate therapies can help you resolve the fractures in your mind and create the reality you want to see.
Key References (full list available in original dissertation):
- Alvarez, A. (2010)
- Bechara, A., et al. (2000; 2005)
- Benoit, R.G., et al. (2014)
- Bion, W.R. (1962)
- Bonnici, H.M. & Maguire, E.A. (2018)
- DeLuca, J. (1992); et al. (1996)
- Etkin, A., et al. (2015)
- Feinberg, T.E. (2010)
- Fotopoulou, A., et al. (2004, 2010)
- Francis, C., et al. (2022)
- Freud, S. (1912, 1914)
- Green, A. (1975)
- Heimann, P. (1950)
- Hiser, J. & Koenigs, M. (2018)
- Loewald, H.W. (1960)
- Mackey, S. & Petrides, M. (2014)
- Metcalf, K., et al. (2007)
- Music, G. (2014)
- Ogden, T.H. (2004a, 2004c, 2017)
- Salas, C. & Turnbull, O.H. (2010); et al. (2019)
- Segal, H. (1957)
- Smith, R. & Solms, M. (2018)
- Solms, M. (2000, 2012, 2013, 2021)
- Solms, M. & Friston, K.J. (2018)
- Tiberg, K. (2014)
- Tranel, D., et al. (2002)
- Turnbull, O.H. & Salas, C. (2017)
- Weiss, H. (2014)
